Health Care for the Elderly

Serious complications rare in elderly patients undergoing hip arthroplasty

Elderly men and women frequently undergo hip arthroplasty and only rarely suffer serious complications, according to a study supported in part by the Agency for Health Care Policy and Research (HS06326). This procedure involves surgical reconstruction or replacement of a painful degenerated hip joint to restore mobility. The study of elderly Medicare patients shows that women had modestly higher total hip arthroplasty rates than men. For both men and women, rates increased with age up to about 80 to 84 years, but declined thereafter. Blacks underwent this procedure at half the rate of whites, but it is unclear whether this was due to racial differences in osteoarthritis, barriers to care, or personal treatment preferences.

About 2.5 percent of patients died within 6 months of the operation, and 3.7 percent died within a year. Mortality was higher in male patients and patients older than 74 years of age. Additional hip surgery was performed in 1.8 percent of total hip arthroplasty cases within 1 year, in 3.2 percent within 2 years, and in 4.2 percent within 3 years. Serious complications were uncommon. Infections were identified in less than 1 percent of patients, even after 2 years. Pulmonary embolism occurred in about 2 percent of total hip arthroplasty patients within 6 months but rarely occurred thereafter.

These findings are based on analysis of a 5 percent sample of the U.S. Medicare population from July 1986 through July 1989. The group included 5,579 elderly patients with total hip arthroplasty performed in the absence of infection, fracture, or previous hip surgery. Most patients (83.3 percent) had osteoarthritis.

For more information, see "Total hip arthroplasty: Use and select complications in the U.S. Medicare population," by John A. Baron, M.D., M.S., M.Sc., Jane Barrett, M.Sc., Jeffrey N. Katz, M.D., M.S., and Matthew H. Liang, M.D., M.P.H., in the January 1996 American Journal of Public Health 86(1), pp. 70-72.

Unregulated use of psychotropic drugs poses danger to elderly residents of board and care facilities

Over one-third (35 percent) of elderly residents of board and care (B&C) facilities use at least one psychotropic (mind-altering) drug such as an antidepressant, antipsychotic, or sedative. And 30 percent of these patients take two to four different psychotropic medications. Moreover, many residents take psychotropic medication with drugs for diabetes, hypertension, Parkinson's disease, and other conditions, according to a study supported in part by the Agency for Health Care Policy and Research (National Research Service Award training grant T32 HS00011). This potentially harmful polypharmacy sparked regulation of medications dispensed in nursing homes in 1987 and probably warrants similar regulation in B&C facilities, suggests Brown University researcher, Diana Spore, Ph.D., the study's principal investigator.

There are approximately 34,000 licensed B&C facilities, with more than 600,000 beds, in the United States, and there are thousands more unlicensed B&C facilities. B&C homes offer protective oversight and supportive services to their residents, most of whom (80 percent) are 65 years of age or older. Residents of B&C facilities typically suffer from dementia and other psychiatric disorders, have chronic physical disorders, and have limitations in their ability to perform activities of daily living. Dr. Spore points out that, although B&C facilities do not have medical directors and usually do not provide nursing care, most of them do store drugs and routinely use unskilled or poorly trained staff to administer them.

The researchers examined 7-day drug use by a sample of 2,054 residents aged 65 and older (most participants were white, female, and widowed) from 410 B&C facilities in 10 States. They found substantial drug duplications and inappropriate drug choices within therapeutic classes, use of multiple psychotropic drugs across classes, and concurrent nonpsychotropic use of such medications, all of which can create problems. For example, some residents (27.4 percent of benzodiazepine users) were taking long-acting benzodiazepines (minor tranquilizers), which have been associated with drug-induced memory impairment and falls. Also, concurrent use of antipsychotics and antidepressants may increase hypotension (abnormally low blood pressure), sedation, and anticholinergic effects (blocking the parasympathetic nerves).

According to the researchers, polypharmacy and suboptimal drug use in B&C facilities may result from inadequate physician and licensed pharmacist oversight, drug prescriptions from multiple physicians, and the absence of primary physicians and/or single pharmacies to review residents' drug use profiles. They recommend that attention be given to the need for systematic drug utilization review in B&C facilities, a program that is mandated in other settings.

For more information, see "Psychotropic use among older residents of board and care facilities," by Dr. Spore, Vincent Mor, Ph.D., Jeffrey Hiris, M.A., and others, in the December 1995 Journal of the American Geriatrics Society 43, pp. 1403-1409.

Alcohol problems in older patients often escape detection

About 1 percent of all hospitalizations for elderly persons in the United States are due to alcoholism, yet alcoholism remains an underrecognized problem among elderly primary care patients. A recent study shows that 1 in 10 primary care patients 60 years of age and older had current evidence of alcoholism, although fewer than half had alcohol abuse documented in their medical records. Older alcoholic patients were more likely than similar-aged nonalcoholic patients to be hospitalized and die, according to the researchers (supported in part by the Agency for Health Care Policy and Research, HS07632 and HS07763).

Christopher M. Callahan, M.D., and William M. Tierney, M.D., of the Indiana University School of Medicine, screened 4,100 patients aged 60 and older for alcoholism, dementia, and depression during regularly scheduled visits at a university-affiliated primary care practice in 1991. They found that 10.5 percent of patients reported at least two symptoms of alcoholism as documented with the CAGE questionnaire. The CAGE consists of four questions about alcohol-related behavior: "Have you ever felt you should Cut down on your drinking? "Have people Annoyed you by criticizing your drinking? "Have you ever felt bad or Guilty about your drinking?" "Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hang-over (Eye-opener)?"

Patients with symptoms of alcoholism were more likely to die than nonalcoholic patients (10.6 percent vs. 6.3 percent). Nevertheless, older alcoholics did not stay in the hospital any longer or visit the emergency room or outpatient department any more often than their nonalcoholic peers in the year after the screening date. In addition, patients with evidence of alcoholism were just as likely to have completed preventive health measures, be smokers and malnourished, and have obstructive lung disease and injuries.

Details are in "Health services use and mortality among older primary care patients with alcoholism," by Drs. Callahan and Tierney, in the December 1995 Journal of the American Geriatrics Society 43 (12), pp. 1378-1383.

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